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Kantharia, Rajesh A., Monalisa Banerjee, Shehnaz R. Kantharia, and Zahoor Ahmad Teli. "A rare anatomical star shaped branching pattern of spinal accessory nerve: A case report with review of literature." IP Indian Journal of Anatomy and Surgery of Head, Neck and Brain 8, no. 3 (October 15, 2022): 104–8. http://dx.doi.org/10.18231/j.ijashnb.2022.025.
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The spinal accessory nerve provides motor innervation to the sternocleidomastoid and trapezius muscle. It is an extremely important structure to be preserved during neck dissection to avoid sequalae related to shoulder dysfunctions. The incidence of shoulder dysfunction and morbidity can be attributed to varied anatomy and branching pattern of the nerve or the contribution by the cervical plexus to the motor innervations of the trapezius muscle. Hence it is important to have knowledge of the varied anatomy and branching pattern of the spinal accessory nerve to avoid the possible shoulder morbidity and dysfunction following neck dissections. Lanisnik B etal’s study showed that there are three recognizable branching patterns of the spinal accessory nerve for innervation of the trapezius muscle. In type 1, the SAN enters the Sternocleidomastoid muscle and a single trapezius muscle branch exits from the posterior border of the SCM after receiving communications from the cervical nerves, especially C2 and C3. In type 2, the motor branch for trapezius muscle separates from the main trunk at level II, before the nerve enters the sternocleido-mastoid muscle. In the type 3 pattern, CN XI enters the SCM in the same way as described in type 1, and the motor branch for the trapezius muscle exits from the SCM muscle behind its posterior border; however, it does not immediately travel to level V and the trapezius muscle, but instead takes a more medial course and mixes with the cervical nerves, predominantly C2 and C3. In this case report, we will discuss an unusual branching pattern of spinal accessory nerve similar to the type 3 variant as explained by Lanisnik that we have encountered during a modified radical neck dissection, in a case of Squamous cell carcinoma of right buccal mucosa.
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Danish, Muhammad Hassan, Haissan Iftikhar, and Mubasher Ikram. "Dual spinal accessory nerve: caution during neck dissection." BMJ Case Reports 13, no. 6 (June 2020): e235487. http://dx.doi.org/10.1136/bcr-2020-235487.
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Preserving the spinal accessory nerve (SAN) is an important step in the modern-day neck dissection to avoid postoperative functional morbidity in patients. This goal can become technically difficult, especially, when rare anatomical variations are encountered. We present a case of dual SAN in a patient undergoing selective neck dissection for oral squamous cell carcinoma. Both SANs were preserved and patient had no shoulder dysfunction postoperatively. We take this opportunity to emphasise that meticulous dissection is the only proven way to preserve the nerve. And that surgeons should be aware of this anatomical variation. SAN should be subjected to minimal traction during neck dissection to avoid tension neuropraxia and long-term shoulder dysfunction.
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Flores, Leandro Pretto. "Suprascapular nerve release for treatment of shoulder and periscapular pain following intracranial spinal accessory nerve injury." Journal of Neurosurgery 109, no. 5 (November 2008): 962–66. http://dx.doi.org/10.3171/jns/2008/109/11/0962.
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Iatrogenic injury to the spinal accessory nerve is one of the most common causes of trapezius muscle palsy. Dysfunction of this muscle can be a painful and disabling condition because scapular winging may impose traction on the soft tissues of the shoulder region, including the suprascapular nerve. There are few reports regarding therapeutic options for an intracranial injury of the accessory nerve. However, the surgical release of the suprascapular nerve at the level of the scapular notch is a promising alternative approach for treatment of shoulder pain in these cases. The author reports on 3 patients presenting with signs and symptoms of unilateral accessory nerve injury following resection of posterior fossa tumors. A posterior approach was used to release the suprascapular nerve at the level of the scapular notch, transecting the superior transverse scapular ligament. All patients experienced relief of their shoulder and scapular pain following the decompressive surgery. In 1 patient the primary dorsal branch of the C-2 nerve root was transferred to the extracranial segment of the accessory nerve, and in the other 2 patients a tendon transfer (the Eden–Lange procedure) was used. Results from this report show that surgical release of the suprascapular nerve is an effective treatment for shoulder and periscapular pain in patients who have sustained an unrepairable injury to the accessory nerve.
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McGarvey, A. C., G. R. Hoffman, P. G. Osmotherly, and P. E. Chiarelli. "Intra-operative monitoring of the spinal accessory nerve: a systematic review." Journal of Laryngology & Otology 128, no. 9 (August 29, 2014): 746–51. http://dx.doi.org/10.1017/s0022215113002934.
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AbstractObjective:To investigate evidence that intra-operative nerve monitoring of the spinal accessory nerve affects the prevalence of post-operative shoulder morbidity and predicts functional outcome.Methods:A search of the Medline, Scopus and Cochrane databases from 1995 to October 2012 was undertaken, using the search terms ‘monitoring, intra-operative’ and ‘accessory nerve’. Articles were included if they pertained to intra-operative accessory nerve monitoring undertaken during neck dissection surgery and included a functional shoulder outcome measure. Further relevant articles were obtained by screening the reference lists of retrieved articles.Results:Only three articles met the inclusion criteria of the review. Two of these included studies suggesting that intra-operative nerve monitoring shows greater specificity than sensitivity in predicting post-operative shoulder dysfunction. Only one study, with a small sample size, assessed intra-operative nerve monitoring in neck dissection patients.Conclusion:It is unclear whether intra-operative nerve monitoring is a useful tool for reducing the prevalence of accessory nerve injury and predicting post-operative functional shoulder outcome in patients undergoing neck dissection. Larger, randomised studies are required to determine whether such monitoring is a valuable surgical adjunct.
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Raj, Sagaya, Shuaib Merchant, Azeem Mohiyuddin, Oomen LNU, and Philip John Kottaram. "Electromyographic Assessment of Accessory Nerve Function Following Nerve Sparing Neck Dissection." International Journal of Head and Neck Surgery 4, no. 1 (2013): 19–23. http://dx.doi.org/10.5005/jp-journals-10001-1130.
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ABSTRACT Aims To assess preoperative and postoperative shoulder function by electromyography (EMG) in spinal accessory nerve (SAN) sparing neck dissections in head and neck cancers. Materials and methods A prospective study was done on 50 patients (51 shoulders) with histopathologically proven head and neck cancers with N0 or N1 neck who underwent nerve sparing neck dissections. Patients were assessed preoperatively and postoperatively at 3 weeks and 3 months by needle EMG and muscle strength tests of upper trapezius. Results and interpretation: At 3 weeks postoperatively, 11 shoulders (39.3%) in FND group and four shoulders (33.3%) in modified radical neck dissection (MRND) group showed severely abnormal EMG, while in supraomohyoid neck dissection (SOHND) group only two (18.2%) shoulders showed severely abnormal EMG. All patients who underwent nerve sparing neck dissections showed improvement in at least one category on the second electromyogram at 3 months. This could be attributed to neuropraxia or transient devascularization of the accessory nerve. In our study, 11 patients in FND group showed severely abnormal EMG finding, but they did not have as great a degree of shoulder dysfunction as would be expected. This could be due to factors like preoperative condition of other synergistic shoulder girdle muscles, postoperative exercises, etc. Conclusion SAN injuries are common in all types of nerve sparing neck dissections requiring aggressive physiotherapy for an improved shoulder function. To conclude, in patients in whom it is oncologically sound, nerve sparing neck dissections offers significant benefit in terms of shoulder function. How to cite this article Mohiyuddin A, Raj S, Merchant S, Oomen, Kottaram PJ. Electromyographic Assessment of Accessory Nerve Function Following Nerve Sparing Neck Dissection. Int J Head and Neck Surg 2013;4(1):19-23.
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OGINO, T., M. SUGAWARA, A. MINAMI, H. KATO, and N. OHNISHI. "Accessory Nerve Injury: Conservative or Surgical Treatment?" Journal of Hand Surgery 16, no. 5 (October 1991): 531–36. http://dx.doi.org/10.1016/0266-7681(91)90109-2.
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In order to clarify the functional prognosis of accessory nerve injury after nerve repair and non-surgical treatment, 27 of our cases with accessory nerve injury were studied. 20 cases were followed up for more than 8 months. In ten cases treated conservatively, the dull feeling and hypaesthesia did not improve. However, pain and dysfunction of the shoulder improved in half of these cases. In ten cases treated surgically, nerve suture was performed in two cases, nerve graft in five cases and neurolysis in three cases. In the surgically treated group, subjective complaints disappeared in all cases, but hypaesthesia or contracture of the shoulder persisted in three cases. Surgical treatment of the accessory nerve is recommended in fresh cases with complete paralysis and in cases in which there is no sign of nerve recovery within one year after the original injury.
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Holan, Cole A., Brent M. Egeland, and Steven L. Henry. "Isolated Spinal Accessory Nerve Palsy from Volleyball Injury." Archives of Plastic Surgery 49, no. 03 (May 2022): 440–43. http://dx.doi.org/10.1055/s-0042-1748660.
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AbstractSpinal accessory nerve (SAN) palsy is typically a result of posterior triangle surgery and can present with partial or complete paralysis of the trapezius muscle and severe shoulder dysfunction. We share an atypical case of a patient who presented with SAN palsy following an injury sustained playing competitive volleyball. A 19-year-old right hand dominant competitive volleyball player presented with right shoulder weakness, dyskinesia, and pain. She injured the right shoulder during a volleyball game 2 years prior when diving routinely for a ball. On physical examination she had weakness of shoulder shrug and a pronounced shift of the scapula when abducting or forward flexing her shoulder greater than 90 degrees. Manual stabilization of the scapula eliminated this shift, so we performed scapulopexy to stabilize the inferior angle of the scapula. At 6 months postoperative, she had full active range of motion of the shoulder. SAN palsy can occur following what would seem to be a routine volleyball maneuver. This could be due to a combination of muscle hypertrophy from intensive volleyball training and stretch sustained while diving for a ball. Despite delayed presentation and complete atrophy of the trapezius, a satisfactory outcome was achieved with scapulopexy.
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McGarvey, Aoife C., Pauline E. Chiarelli, Peter G. Osmotherly, and Gary R. Hoffman. "Physiotherapy for accessory nerve shoulder dysfunction following neck dissection surgery: A literature review." Head & Neck 33, no. 2 (January 14, 2011): 274–80. http://dx.doi.org/10.1002/hed.21366.
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Lehn, Carlos Neutzling, Luciana Pereira Lima, and Ali Amar. "Spinal Accessory Nerve Neuropathies Followng Neck Dissection." Otolaryngology–Head and Neck Surgery 139, no. 2_suppl (August 2008): P45. http://dx.doi.org/10.1016/j.otohns.2008.05.147.
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Objective To evaluate through electromyography (EMG) the injury to the 11th cranial nerve following neck dissection. Methods Prospective study with 60 patients submitted to neck dissection as part of treatment of head and neck tumors. All the cases underwent physiotherapic evaluation of shoulder dysfunction. Nerve integrity was evaluated pre- and postoperatively through surface EMG registering the electric activity of descendent fibers of trapezius muscle during maximal isometric voluntary contraction. The patients were grouped according the type of neck dissection, presence of shoulder pain, impairment during abduction movement, and hypotrophy or atrophy of trapezius muscle. Results The action potential had mean and standard deviation of 61,7±31,6mcV in preoperative evaluation and 15,6±12,4mcV in postoperative evaluation (p<0.001). According to the neck dissection extension, there were mean values of 18,8±14,2mcV after dissection includiog level IIb and 18,8±14,2 mcV after dissection including levels IIb and V (p<0.002). Conclusions Surface EMG is a sensitive and painless for 11th cranial nerve disfunction evaluation. In all cases, the superior fibers of trapezius muscle were affected with presence of pain and impairment abduction movement of the arm. The results suggest the benefit of trapezius muscle EMG to confirm the diagnosis and early physiotherapic intervention in neuropathies of the 11th cranial nerve.
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McGarvey, Aoife C., Peter Grant Osmotherly, Gary R. Hoffman, and Pauline E. Chiarelli. "Scapular Muscle Exercises Following Neck Dissection Surgery for Head and Neck Cancer: A Comparative Electromyographic Study." Physical Therapy 93, no. 6 (June 1, 2013): 786–97. http://dx.doi.org/10.2522/ptj.20120385.
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Background Shoulder pain and dysfunction can occur following neck dissection surgery for cancer. These conditions often are due to accessory nerve injury. Such an injury leads to trapezius muscle weakness, which, in turn, alters scapular biomechanics. Objective The aim of this study was to assess which strengthening exercises incur the highest dynamic activity of affected trapezius and accessory scapular muscles in patients with accessory nerve dysfunction compared with their unaffected side. Design A comparative design was utilized for this study. Methods The study was conducted in a physical therapy department. Ten participants who had undergone neck dissection surgery for cancer and whose operated side demonstrated clinical signs of accessory nerve injury were recruited. Surface electromyographic activity of the upper trapezius, middle trapezius, rhomboid major, and serratus anterior muscles on the affected side was compared dynamically with that of the unaffected side during 7 scapular strengthening exercises. Results Electromyographic activity of the upper and middle trapezius muscles of the affected side was lower than that of the unaffected side. The neck dissection side affected by surgery demonstrated higher levels of upper and middle trapezius muscle activity during exercises involving overhead movement. The rhomboid and serratus anterior muscles of the affected side demonstrated higher levels of activity compared with the unaffected side. Limitations Exercises were repeated 3 times on one occasion. Muscle activation under conditions of increased exercise dosage should be inferred with caution. Conclusions Overhead exercises are associated with higher levels of trapezius muscle activity in patients with accessory nerve injury following neck dissection surgery. However, pain and correct scapular form must be carefully monitored in this patient group during exercises. Rhomboid and serratus anterior accessory muscles may have a compensatory role, and this role should be considered during rehabilitation.
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Gatskiy, Alexander A., Ihor B. Tretyak, Vitalii I. Tsymbaliuk, Hao Jiang, Iaroslav V. Tsymbaliuk, and Albina I. Tretiakova. "Spinal accessory to suprascapular nerve transfer in brachial plexus injury: outcomes of anterior vs. posterior approach to the suprascapular nerve at associated ipsilateral spinal accessory nerve injury." Ukrainian Neurosurgical Journal 28, no. 2 (June 24, 2022): 37–45. http://dx.doi.org/10.25305/unj.255792.
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Objective: The spinal accessory nerve (Acc) is susceptible to trauma in at least 6% of cases of brachial plexus injury (BPI). The impaired Acc function disables its utilization for transfer to the suprascapular nerve (SS). The selection of approach to SS is highly dependant on the anatomy of BPI. The purpose of this study was to determine the incidence of the anterior-posterior approach of Acc to SS transfer in BPI and associated functional outcomes. Methods. Twenty nine patients with BP/Acc associated injury were included. Ten patients underwent the transfer of Acc to SS by the anterior approach (AA), 19 patients – by the posterior approach (PA). Nine nerve transfers through AA and one nerve transfer through PA required the interposition of an autologous nerve graft. The functioning of the supra-/infraspinatus muscle was evaluated at 9 and 15mos. on the basis of the MRC and the external rotation (ER) range. ER more than +400 beyond the sagittal plane was regarded as effective recovery of function. Results. Impaired function (M3 or lower on MRC) of the lower trapezius muscle was associated with preserved anatomy of the SS in the supraclavicular region in 9 out of 10 cases. Eighteen patients (62%) recovered to M3 and higher (shoulder stability), 11of these (38%) showed recovery to M4-M5. Five of all patients recovered to M4-M5 and were able to produce ER within the effective ROM (+400-600 of ER). After the AA to the SS, shoulder stability was restored in 60% of cases (M4-M5 in 30%). After the PA to the SS, shoulder stability was restored in 74% of cases (M4-M5 in 42%). Only non-complete BPI showed effective recovery of power and function in terms of less than 6 mos. after injury. PA to SS with no graft provided shoulder stability in 72% of cases, AA to the SS and the graft interposition ensured shoulder stability in 50% of cases. Conclusions. The incidence of AA to the SS was 35%, PA – 65%; preserved anatomy of the SS in supraclavicular region was associated with an increased risk of trapezius muscle dysfunction; the PA to SS and consecutive direct end-to-end transfer of Acc showed better results compared to other combinations of nerve transfers in providing shoulder stability.
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Jindal, Rohit, Kamal Kishor Lakhera, Pinakin Patel, Suresh Singh, Ravinder Singh Gothwal, Raj Govind Sharma, and Krishan Gopal Sharma. "Spinal Accessory Nerve Duplication – A Rare Anatomical Consternation During Neck Dissectio." Asian Pacific Journal of Cancer Care 6, no. 4 (November 28, 2021): 539–41. http://dx.doi.org/10.31557/apjcc.2021.6.4.539-541.
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Prevention of the spinal accessory nerve (SAN) is an indispensable aspect of the functional neck dissection surgery to avoid highly disabling shoulder syndrome postoperatively. This requires comprehensive knowledge of the anatomy of SAN and its variations. Rare anatomical variations like SAN duplication can result in an inadvertant injury to the SAN. We report a case of duplication of SAN, which was encountered while doing a functional neck dissection surgery for oral squamous cell carcinoma. No iatrogenic injury occurred during the surgery and neither there was any SAN dysfunction post-operatively. Meticulous dissection and consistent identification of SAN, along with vast anatomical knowledge is the key to the preservation of the nerve during the surgery. This report aims to broaden our anatomical knowledge of SAN and also discuss the clinical implications and literature pertaining to the duplication of SAN.
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Chen, Yueh-Hsia, Cheng-Ya Huang, Wei-An Liang, Chi-Rung Lin, and Yuan-Hung Chao. "Effects of Conscious Control of Scapular Orientation in Oral Cancer Survivors With Scapular Dyskinesis: A Randomized Controlled Trial." Integrative Cancer Therapies 20 (January 2021): 153473542110408. http://dx.doi.org/10.1177/15347354211040827.
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Objectives: Spinal accessory nerve dysfunction is one of the complications of neck dissection in patients with oral cancer. This study aimed to explore the effects of long-term scapular-focused exercises and conscious control of scapular orientation on scapular movement and quality of life (QoL). Methods: This study was a randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Thirty-six patients with oral cancer were randomly allocated to the motor-control group (scapular-focused exercise + conscious control of scapular orientation) or the regular-exercise group (scapular-focused exercises only). Both groups received conventional physical therapy after neck dissection for 3 months. Shoulder pain intensity, active range of motion (AROM) of shoulder abduction, scapular muscle strength and activity under maximal voluntary isometric contraction (MVIC), scapular muscle activity when performing scapular movements, and QoL were measured at baseline, 1 month after the start of the intervention, and the end of the intervention. Results: Both groups showed significant improvement in all outcomes except shoulder pain intensity. After the 3-month intervention, the motor-control group had more significant improvement in AROM of shoulder abduction with a 19° difference (95% CI: 10-29, P < .001), muscle strength of upper trapezius with an 11 N difference (95% CI: 2-20; P = .021), and QoL than the regular-exercise group. When performing shoulder horizontal adduction and flexion, the relative value (%MVIC) of serratus anterior was smaller in the motor-control group with a 106%MVIC difference (95% CI: 7-205, P = .037). Conclusions: Scapular-focused exercises have promising effects on spinal accessory nerve dysfunction. Combining scapular-focused exercises with conscious control of scapular orientation has more remarkable benefits on AROM of shoulder abduction, UT muscle strength, and muscle activation pattern than the scapular-focused exercises alone. Conscious control of scapular orientation should be considered to integrate into scapular-focused exercises in patients with oral cancer and scapular dyskinesis. Trial registry name and URL, and registration number: ClinicalTrials.gov (URL: https://clinicaltrials.gov ; Approval No: NCT03545100)
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Gane, Elise M., Shaun P. O’Leary, Anna L. Hatton, Benedict J. Panizza, and Steven M. McPhail. "Neck and Upper Limb Dysfunction in Patients following Neck Dissection: Looking beyond the Shoulder." Otolaryngology–Head and Neck Surgery 157, no. 4 (July 25, 2017): 631–40. http://dx.doi.org/10.1177/0194599817721164.
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Objective To measure patient-perceived upper limb and neck function following neck dissection and to investigate potential associations between clinical factors, symptoms, and function. Study Design Cross-sectional. Setting Two tertiary hospitals in Brisbane, Australia. Subjects and Methods Inclusion criteria: patients treated with neck dissection (2009-2014). Exclusion criteria: aged <18 years, accessory nerve or sternocleidomastoid sacrifice, previous neck dissection, preexisting shoulder/neck injury, and inability to provide informed consent (cognition, insufficient English). Primary outcomes were self-reported function of the upper limb (Quick Disabilities of the Arm, Shoulder, and Hand) and neck (Neck Disability Index). Secondary outcomes included demographics, oncological management, self-efficacy, and pain. Generalized linear models were prepared to examine relationships between explanatory variables and self-reported function. Results Eighty-nine participants (male n = 63, 71%; median age, 62 years; median 3 years since surgery) reported mild upper limb and neck dysfunction (median [quartile 1, quartile 3] scores of 11 [3, 32] and 12 [4, 28], respectively). Significant associations were found between worse upper limb function and longer time since surgery (coefficient, 1.76; 95% confidence interval [CI], 0.01-3.51), having disease within the thyroid (17.40; 2.37-32.44), postoperative radiation therapy (vs surgery only) (13.90; 6.67-21.14), and shoulder pain (0.65; 0.44-0.85). Worse neck function was associated with metastatic cervical lymph nodes (coefficient, 6.61; 95% CI, 1.14-12.08), shoulder pain (0.19; 0.04-0.34), neck pain (0.34; 0.21-0.47), and symptoms of neuropathic pain (0.61; 0.25-0.98). Conclusion Patients can experience upper limb and neck dysfunction following nerve-preserving neck dissection. The upper quadrant as a whole should be considered when assessing rehabilitation priorities after neck dissection.
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Ye, Xuan, Yun-Dong Shen, Jun-Tao Feng, and Wen-Dong Xu. "Nerve fascicle transfer using a part of the C-7 nerve for spinal accessory nerve injury." Journal of Neurosurgery: Spine 28, no. 5 (May 2018): 555–61. http://dx.doi.org/10.3171/2017.8.spine17582.
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OBJECTIVESpinal accessory nerve (SAN) injury results in a series of shoulder dysfunctions and continuous pain. However, current treatments are limited by the lack of donor nerves as well as by undesirable nerve regeneration. Here, the authors report a modified nerve transfer technique in which they employ a nerve fascicle from the posterior division (PD) of the ipsilateral C-7 nerve to repair SAN injury. The technique, first performed in cadavers, was then undertaken in 2 patients.METHODSSix fresh cadavers (12 sides of the SAN and ipsilateral C-7) were studied to observe the anatomical relationship between the SAN and C-7 nerve. The length from artificial bifurcation of the middle trunk to the point of the posterior cord formation in the PD (namely, donor nerve fascicle) and the linear distance from the cut end of the donor fascicle to both sites of the jugular foramen and medial border of the trapezius muscle (d-SCM and d-Traps, respectively) were measured. Meanwhile, an optimal route for nerve fascicle transfer (NFT) was designed. The authors then performed successful NFT operations in 2 patients, one with an injury at the proximal SAN and another with an injury at the distal SAN.RESULTSThe mean lengths of the cadaver donor nerve fascicle, d-SCM, and d-Traps were 4.2, 5.2, and 2.5 cm, respectively. In one patient who underwent proximal SAN excision necessitated by a partial thyroidectomy, early signs of reinnervation were seen on electrophysiological testing at 6 months after surgery, and an impaired left trapezius muscle, which was completely atrophic preoperatively, had visible signs of improvement (from grade M0 to grade M3 strength). In the other patient in whom a distal SAN injury was the result of a neck cyst resection, reinnervation and complex repetitive discharges were seen 1 year after surgery. Additionally, the patient’s denervated trapezius muscle was completely resolved (from grade M2 to grade M4 strength), and her shoulder pain had disappeared by the time of final assessment.CONCLUSIONSNFT using a partial C-7 nerve is a feasible and efficacious method to repair an injured SAN, which provides an alternative option for treatment of SAN injury.
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Rukmana Tri Pratistha, Indra, Nyoman Gede Bimantara, I. Gede Mahardika Putra, Made Bramantya Karna, Anak Agung Gde Yuda Asmara, and Putu Feryawan Meregawa. "Nerves Transfer Procedure in Patients with Left Upper Extremities Weakness Following Gunshot Wounds: A Case Report." Open Access Macedonian Journal of Medical Sciences 9, no. C (September 5, 2021): 140–45. http://dx.doi.org/10.3889/oamjms.2021.6393.
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BACKGROUND: Gunshot wounds (GSWs) to the extremities can result in damage to the neurovascular structure which results in high morbidity and loss of function. According to the Centers for Disease Control report, the incidence of non-fatal GSWs has increased in the past decade. Trauma to the brachial plexus is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. Early exploration and reconstruction of peripheral nerve trauma are still being debated to this day. However, most recommend surgical exploration when the suspicion of neurovascular trauma is very high based on clinical findings. Nerve transfer is one of the recommended methods of nerve reconstruction even in pre-ganglionic lesions. We report a case of a patient with weakness of the upper limb after a gunshot wound to his left shoulder. Based on clinical considerations and investigations, nerve transfer procedure is carried out to restore patient’s shoulder function. CASE REPORT: Male, 32 years old, working as a policeman, complained difficulty on moving his shoulder for 3 months. Patients had a history of GSWs to the left shoulder which also results in a left clavicular fracture. First aid, debridement, and fracture management were performed at Bhayangkara Hospital, Palu. Physical examination revealed winging scapula positive on his left shoulder, shoulder abduction 5/1, and hypoesthesia at left C5 level. Electromyographic examination revealed lesions on the left posterior chord and left brachial plexus. Based on clinical findings and supporting examination, we performed nerve transfers procedure from the accessory nerve to suprascapular notch. In the previous study, 63% of cases GSWs associated with nerve dysfunction. About 75% of patients with nerve palsy are associated with nerve lacerations during surgical exploration. However, many surgeons continue to recommend early exploration after GSWs to the upper extremities, especially in patients who will undergo surgical treatment for other indications. Based on this, we suggest the probable cause of brachial plexus lesions in this case resulted from gunshot wound which injures the brachial plexus or as a complication from previous procedures. Surgery that is too early can interfere with the spontaneous reinnervation process, but late surgical procedures can result in failure of reinnervation. In general, optimal time is set between 3 and 6 months after trauma. Nerve transfer is one method of reconstructing peripheral nerve lesions that can be applied to pre-ganglionic or post-ganglionic lesions. CONCLUSION: This procedure has several benefits, namely, the proximity of the donor and the recipient nerve anatomy, shorter operating time and does not require grafts. Brachial plexus trauma due to trauma or non-trauma together has an impact on the patient’s quality of life. However, advances in surgical techniques and further understanding of nerve physiology have led clinicians and patients to better outcomes. The current trend of treatment strategies for brachial plexus trauma is surgical reconstruction with the nerve transfer procedure.
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Targino Costa, Márcia G. S., Roberto A. Lima, Claudia Rabello, Rosana Lucena, Silvia Bacelar, Fernando Luiz Dias, and Mauro Barbosa. "S167 – Supportive Physical Therapy on Head and Neck Cancer Patients." Otolaryngology–Head and Neck Surgery 139, no. 2_suppl (August 2008): P132. http://dx.doi.org/10.1016/j.otohns.2008.05.341.
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Objectives 1) The aim of this paper is to identify the supportive profile of physical therapy attendments at Brazilian National Cancer Institute. 2) Look for patients’ main demands and their dysfunctional characteristics. Methods The physiotherapeutic consultations for head and neck cancer patients performed between 02/01/2007 and 12/31/2007 were retrospectively analyzed in their quantitative and qualitative aspects. Results 1405 attendments were reviewed including 15% of first-time patients. 60% of the consultations were to male patients. The main dysfunctions identified were on accessory nerve (27, 7%), followed by TMJ disorders (27, 6%), breathing complications (10, 6%), and restricted neck movement (10, 5%). The less frequent complications were paresis of facial nerve mandibular branch (4, 7%) and donor site dysfunctions (2, 5%). Pain was a complaint present in 39 (7%) of these attendments, and analgesia was responsible for 21 (2%) of the total procedures performed. In 24% of realized consults, 3 or more procedures were necessary, representing multiple dysfunctions on each patient. Conclusions Secondary dysfunctions caused by head and neck cancer and/or its indicated treatment are important and quite frequent. Shoulder and TMJ dysfunctions as well as breathing disorders were the most frequent complications observed. Pain was seen in a significant number of patients under physical therapy. Patients’ total care has the intention of preventing known complications, and to allow early rehabilitation and sequelae management of installed dysfunctions.
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Ebersold, Michael J., and Lynn M. Quast. "Long-term results of spinal accessory nerve-facial nerve anastomosis." Journal of Neurosurgery 77, no. 1 (July 1992): 51–54. http://dx.doi.org/10.3171/jns.1992.77.1.0051.
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✓ A number of methods have been developed to reduce the cosmetic and functional disability resulting from facial nerve loss. It has often been suggested that the major trunk of the spinal accessory nerve should not be sacrificed for providing dynamic facial function because of shoulder disability and pain. A review of Mayo Clinic records has revealed that, between the years of 1975 and 1983, 25 patients underwent spinal accessory nerve-facial nerve anastomosis using the major division (branch to the trapezius muscle) of the spinal accessory nerve. There were 11 males and 14 females, ranging in age from 16 to 60 years (mean 41 years). The interval between facial nerve loss and anastomosis was 1 week to 34 months (mean 4.62 months). The duration of follow-up study ranged from 7 to 15 years (mean 10.8 years). Twenty patients had no complaints or symptoms related to their shoulder or arm at the time of this review and no patient had significant shoulder morbidity. The facial function achieved was “minimal” in five cases, “moderate” in six, and good to excellent in 14. Most patients appeared to benefit significantly from the spinal accessory nerve-facial nerve anastomosis. The morbidity of the procedure seemed quite minimal even in the young and active. The authors continue to believe that the spinal accessory nerve-facial nerve anastomosis, even when using the major trunk of the spinal accessory nerve, is a very useful and beneficial procedure.
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Augustine, Haley, Matthew Choi, and James Bain. "Dorsal Scapular Nerve Transfer to Suprascapular Nerve." Plastic Surgery Case Studies 3 (December 1, 2017): 2513826X1775111. http://dx.doi.org/10.1177/2513826x17751114.
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Background: Obstetrical brachial plexus injury involving the suprascapular nerve is conventionally treated using an accessory nerve transfer or grafting. In circumstances where the accessory nerve is unsuitable, transfer of nerves with redundant function may be an alternate method of restoring function. Methods: This case describes the surgical technique of restoring shoulder function by reinnervating the musculature of the suprascapular nerve with a dorsal scapular nerve transfer in a patient with an obstetrical brachial plexus injury. Results: At 15 months post-operatively, the patient shoulder movement improved from zero muscle contraction to full range of motion against gravity measured by the active movement scale. His composite mallet score was 23 out of 25, with perfect scores in abduction and external rotation. Secondary surgery was not required. Conclusions: This case demonstrates a novel alternative to suprascapular nerve reinnervation in circumstances where the accessory nerve is unavailable, damaged, or otherwise suboptimal. Successful results were achieved, thus warranting consideration in clinical practice as well as further exploration and study.
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Bertelli, Jayme Augusto, and Marcos Flávio Ghizoni. "Combined Injury of the Accessory Nerve and Brachial Plexus." Neurosurgery 68, no. 2 (February 1, 2011): 390–96. http://dx.doi.org/10.1227/neu.0b013e318201d7d9.
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Abstract BACKGROUND: Stretch-induced spinal accessory nerve palsy has been considered extremely rare, with only a few cases reported. OBJECTIVE: In 357 patients with stretch lesions of the brachial plexus, we investigated the prevalence, course, and surgical treatment of accessory nerve palsy. METHODS: Accessory nerve palsy was ascertained when the patient was unable to shrug the ipsilateral shoulder. Patients underwent brachial plexus reconstruction between 6 and 8 months after trauma. To confirm paralysis, during surgery, the accessory nerve was stimulated electrically. RESULTS: Accessory nerve palsy occurred in 19 of the 327 patients (6%) with upper type or complete palsy of the brachial plexus. Proximal injuries of the accessory nerve accompanied by voice alteration and complete palsy of the sternocleidomastoid and trapezius muscle occurred in 2 patients. Proximal palsy without vocal alterations was observed in 6 patients. Palsy of the trapezius muscle with preservation of the sternocleidomastoid muscle occurred in 11 patients. All 7 patients who demonstrated muscle contractions upon electrical stimulation of the accessory nerve during surgery recovered completely. Patients with surgical reconstruction of the accessory nerve through grafting (n = 2) or repair by platysma motor nerve transfer (n = 2) recovered active shoulder shrugging within 36 months of surgery. Seven of the 8 patients without accessory nerve reconstruction recovered from their drop shoulder and head tilt, but remained unable to shrug. CONCLUSION: If intraoperative electrical stimulation produces contraction of the upper trapezius muscle, no repair is needed. In proximal injuries, the platysma motor branch should be transferred to the accessory nerve; whereas in paralysis distal to the sternocleidomastoid muscle, the accessory nerve should be explored and grafted.
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Erisen, Levent, Bekir Basel, Jale Irdesel, Mehmet Zarifoglu, Hakan Coskun, Oguz Basut, Ilker Tezel, Ibrahim Hizalan, and Selcuk Onart. "Shoulder function after accessory nerve-sparing neck dissections." Head & Neck 26, no. 11 (November 2004): 967–71. http://dx.doi.org/10.1002/hed.20095.
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Maldonado, Andrés A., and Robert J. Spinner. "Lateral pectoral nerve transfer for spinal accessory nerve injury." Journal of Neurosurgery: Spine 26, no. 1 (January 2017): 112–15. http://dx.doi.org/10.3171/2016.5.spine151458.
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Spinal accessory nerve (SAN) injury results in loss of motor function of the trapezius muscle and leads to severe shoulder problems. Primary end-to-end or graft repair is usually the standard treatment. The authors present 2 patients who presented late (8 and 10 months) after their SAN injuries, in whom a lateral pectoral nerve transfer to the SAN was performed successfully using a supraclavicular approach.
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Novak, Christine B., and Susan E. Mackinnon. "Patient Outcome after Surgical Management of an Accessory Nerve Injury." Otolaryngology–Head and Neck Surgery 127, no. 3 (September 2002): 221–24. http://dx.doi.org/10.1067/mhn.2002.126803.
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OBJECTIVE: This study assessed patient outcome following surgical reconstruction of the accessory nerve after an iatrogenic injury. STUDY DESIGN: A retrospective chart review of 8 patients was performed. RESULTS: There were 3 men and 5 women in the study, and the mean time between injury and nerve graft/repair surgery was 5 months. Four injuries were sustained during a lymph node biopsy. Electromyography revealed a complete accessory nerve injury in all cases. In 6 cases, a nerve graft was required (mean length, 3.6 cm), and in 2 cases, a direct nerve repair was possible. The trapezius muscle was successfully reinnervated in all cases. In total, full shoulder abduction was achieved in 6 cases; in the remaining 2 cases, the patients achieved shoulder abduction to 90°. CONCLUSION: Functional deficit after accessory nerve injury is significant. Nerve graft/repair reconstruction reliably yields a satisfactory result, providing good scapular rotation and thus good shoulder function.
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Göransson, Harry, Olli V. Leppänen, and Martti Vastamäki. "Patient outcome after surgical management of the spinal accessory nerve injury: A long-term follow-up study." SAGE Open Medicine 4 (January 1, 2016): 205031211664573. http://dx.doi.org/10.1177/2050312116645731.
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Objectives: A lesion in the spinal accessory nerve is typically iatrogenic: related to lymph node biopsy or excision. This injury may cause paralysis of the trapezius muscle and thus result in a characteristic group of symptoms and signs, including depression and winging of the scapula, drooped shoulder, reduced shoulder abduction, and pain. The elements evaluated in this long-term follow-up study include range of shoulder motion, pain, patients’ satisfaction, delay of surgery, surgical procedure, occupational status, functional outcome, and other clinical findings. Methods: We reviewed the medical records of a consecutive 37 patients (11 men and 26 women) having surgery to correct spinal accessory nerve injury. Neurolysis was the procedure in 24 cases, direct nerve repair for 9 patients, and nerve grafting for 4. Time elapsed between the injury and the surgical operation ranged from 2 to 120 months. The patients were interviewed and clinically examined after an average of 10.2 years postoperatively. Results: The mean active range of movement of the shoulder improved at abduction 44° (43%) in neurolysis, 59° (71%) in direct nerve repair, and 30° (22%) in nerve-grafting patients. No or only slight atrophy of the trapezius muscle was observable in 75%, 44%, and 50%, and no or controllable pain was observable in 63%, 56%, and 50%. Restriction of shoulder abduction preceded deterioration of shoulder flexion. Patients’ overall dissatisfaction with the state of their upper extremity was associated with pain, lower strength in shoulder movements, and occupational problems. Conclusion: We recommend avoiding unnecessary delay in the exploration of the spinal accessory nerve, if a neural lesion is suspected.
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Abdouni, Yussef Ali, Gabriel Faria Checoli, Horacio Cardoso Salles Filho, Antonio Carlos da Costa, Ivan Chakkour, and Patricia Maria de Moraes Barros Fucs. "ASSESSMENT OF THE RESULTS OF ACCESSORY TO SUPRASCAPULAR NERVE TRANSFER." Acta Ortopédica Brasileira 26, no. 5 (October 2018): 332–34. http://dx.doi.org/10.1590/1413-785220182605193532.
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ABSTRACT Objective: Nerve transfers are an alternative in the reconstruction of traumatic brachial plexus injuries. In this study, we report the results of branchial plexus reconstruction using accessory to suprascapular nerve transfer. Methods: Thirty-three patients with traumatic brachial plexus injuries underwent surgical reconstruction with accessory to suprascapular nerve transfers. The patients were divided into groups in which surgery was performed either within 6 months after the injury or more than 6 months after the injury. Results were assessed using the Constant score. Results: There was no significant difference between the groups with respect to the Constant score. Conclusion: Accessory to suprascapular nerve transfer was not an efficient method for recovering active ROM or strength in the shoulder. However, it effectively improved pain control and shoulder stability. Level of evidence II, Retrospective Study.
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Akgun, Kenan, Ilknur Aktas, and Kayihan Uluc. "P186 Shoulder pain due to spinal accessory nerve injury." Clinical Neurophysiology 119 (May 2008): S118. http://dx.doi.org/10.1016/s1388-2457(08)60457-5.
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Cambon-Binder, Adeline, Lynda Preure, Heba Dubert-Khalifa, Pierre-Sylvain Marcheix, and Zoubir Belkheyar. "Spinal accessory nerve repair using a direct nerve transfer from the upper trunk: results with 2 years follow-up." Journal of Hand Surgery (European Volume) 43, no. 6 (February 12, 2018): 589–95. http://dx.doi.org/10.1177/1753193418755618.
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Spinal accessory nerve grafting requires identification of both nerve stumps in the scar tissue, which is sometimes difficult. We propose a direct nerve transfer using a fascicle from the posterior division of the upper trunk. We retrospectively reviewed 11 patients with trapezius palsy due to an iatrogenic injury of the spinal accessory nerve in nine cases. The mean age was 38 years (range 21–59). Preoperatively, patients showed shoulder weakness and limited range of motion. At a mean follow-up of 25 months, active shoulder abduction improvement averaged 57°. Trapezius muscle strength graded M4 or M5 in 10 cases and M3 in one case. No deltoid or triceps impairment was reported. Scapula kinematics was considered normal in seven patients. This technique gave satisfactory functional results and may be an alternative to spinal accessory nerve grafting for the management of trapezius palsies if direct repair is not feasible. Level of evidence: IV
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Hu, S., B. Chu, J. Song, and L. Chen. "Anatomic study of the intercostal nerve transfer to the suprascapular nerve and a case report." Journal of Hand Surgery (European Volume) 39, no. 2 (February 6, 2013): 194–98. http://dx.doi.org/10.1177/1753193413475963.
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The purpose of this study was to investigate the anatomical basis of intercostal nerve transfer to the suprascapular nerve and provide a case report. Thoracic walls of 30 embalmed human cadavers were used to investigate the anatomical feasibility for neurotization of the suprascapular nerve with intercostal nerves in brachial plexus root avulsions. We found that the 3rd and 4th intercostal nerves could be transferred to the suprascapular nerve without a nerve graft. Based on the anatomical study, the 3rd and 4th intercostal nerves were transferred to the suprascapular nerve via the deltopectoral approach in a 42-year-old man who had had C5-7 root avulsions and partial injury of C8, T1 of the right brachial plexus. Thirty-two months postoperatively, the patient gained 30° of shoulder abduction and 45° of external rotation. This procedure provided us with a reliable and convenient method for shoulder function reconstruction after brachial plexus root avulsion accompanied with spinal accessory nerve injury. It can also be used when the accessory nerve is intact but needs to be preserved for better shoulder stability or possible future trapezius transfer.
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Midwinter, Katie, and David Willatt. "Accessory nerve monitoring and stimulation during neck surgery." Journal of Laryngology & Otology 116, no. 4 (April 2002): 272–74. http://dx.doi.org/10.1258/0022215021910735.
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Iatrogenic injury to the spinal accessory nerve following surgical procedures in the neck is well recognized in causing significant morbidity to patients, with shoulder pain and loss of function being particularly problematic. We have used a Magstim Neurosign 100 peripheral nerve monitor, that is most often used in our practice to monitor the facial nerve during middle ear and parotid surgery, to monitor the accessory nerve during neck surgery. Ten patients undergoing accessory nerve-sparing neck dissection, or excision biopsy of neck mass had their accessory nerve monitored during the procedure. No patient suffered injury of the nerve. In several cases the nerve closely adhered to the tissue being resected, and in two cases, the nerve bifurcated or gave off branches. We found that the monitor aided identification and preservation of the nerve.
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Lloyd, S. "Accessory nerve: anatomy and surgical identification." Journal of Laryngology & Otology 121, no. 12 (September 25, 2007): 1118–25. http://dx.doi.org/10.1017/s0022215107000461.
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AbstractThe XIth cranial nerve or accessory nerve provides the motor supply to the sternocleidomastoid and trapezius muscles. It is frequently encountered during neck surgery, and as such is at risk of iatrogenic injury, resulting in the ‘shoulder syndrome’. Historically, the nerve was sacrificed on oncological grounds during radical neck dissection. However, the basis for sacrifice is unfounded in the majority of cases, and accessory nerve sparing selective neck dissection has equal oncological efficacy. The path of the nerve in the neck is very variable, and there is not a wholly reliable landmark for its identification. However, there are a number of methods described in the literature to guide the surgeon in its identification. This paper provides a systematic review of all the methods available for identification of the accessory nerve, and comments on the reliability of each. In doing so, the detailed anatomy of the accessory nerve is also described.
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Mayer, Johannes A., Laura A. Hruby, Stefan Salminger, Gerd Bodner, and Oskar C. Aszmann. "Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk." Journal of Neurosurgery: Spine 31, no. 1 (July 2019): 133–38. http://dx.doi.org/10.3171/2018.12.spine18498.
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OBJECTIVESpinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle.METHODSFive cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented.RESULTSAll 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients.CONCLUSIONSRestoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.
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Orhan, K. S., T. Demirel, B. Baslo, E. K. Orhan, E. A. Yücel, Y. Güldiken, and K. Değer. "Spinal accessory nerve function after neck dissections." Journal of Laryngology & Otology 121, no. 1 (July 3, 2006): 44–48. http://dx.doi.org/10.1017/s0022215106002052.
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The aim of this study was to evaluate spinal accessory nerve function after functional neck dissection (FND) and radical neck dissection (RND) by monitoring the nerve with electromyographic (EMG) examinations. A prospective, double-blind, clinical study was undertaken in 21 patients (42 neck side dissections) operated on for head and neck malignant diseases, separated into two groups: 10 neck sides in the RND group and 32 neck sides in the FND group. Electromyographic examinations were performed pre-operatively and post-operatively in the third week and third and ninth months. Additionally, a questionnaire, modified from the neck dissection impairment index, was applied to all the patients in order to assess shoulder function in the ninth post-operative month.All patients had maximum EMG scores pre-operatively. Following the operation, motor amplitudes decreased in both groups. At the third post-operative month, amplitudes decreased to their lowest values. As expected, the decreases in amplitude and EMG score were more prominent in the RND group. Following reinnervation, the amplitudes of the trapezius motor response increased in the FND group but never reached pre-operative values (during the time of follow up). The FND group scores for pain, neck and shoulder stiffness, and disability in heavy object lifting, light object lifting and reaching overhead were significantly lower than those of the RND group.In FND, one aims to preserve anatomically the spinal accessory nerve, and it is presumed to be intact after the procedure. However, using EMG nerve function monitoring, our study revealed that profound spinal nerve injury was detected immediately after FND surgery, which tended to improve over subsequent months but had not regained its original function by the end of the ninth post-operative month.
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Miyata, Koji, and Hiroyuki Kitamura. "Accessory nerve damages and impaired shoulder movements after neck dissections." American Journal of Otolaryngology 18, no. 3 (May 1997): 197–201. http://dx.doi.org/10.1016/s0196-0709(97)90082-x.
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Bertelli, Jayme Augusto, and Marcos Flávio Ghizoni. "Transfer of the Platysma Motor Branch to the Accessory Nerve in a Patient With Trapezius Muscle Palsy and Total Avulsion of the Brachial Plexus." Neurosurgery 68, no. 2 (February 1, 2011): E567—E570. http://dx.doi.org/10.1227/neu.0b013e318202086c.
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Abstract BACKGROUND AND IMPORTANCE: To report on the successful use of a platysma motor nerve transfer to the accessory nerve in a patient with concomitant trapezius and brachial plexus palsy. CLINICAL PRESENTATION: A 20-year-old man presented with total avulsion of the right brachial plexus combined with palsies of the accessory and phrenic nerve. The patient was operated on 4 months after his injury. The accessory nerve was repaired via direct transfer of the platysma motor branch. The contralateral C7 root was connected to the musculocutaneous nerve, and the hemihypoglossal nerve was grafted to the suprascapular nerve. Two intercostal nerves were attached to the triceps long head motor branch. CONCLUSION: Within 20 months of surgery, the patient regained full reinnervation of the upper trapezius muscle. Elbow flexion scored M3+, and 30° active shoulder abduction was observed. Triceps reinnervation was poor. Platysma motor branch transfer to the accessory nerve is a viable alternative to reinnervate the trapezius muscle.
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Tatla, T., J. Kanagalingam, A. Majithia, and P. M. Clarke. "Upper neck spinal accessory nerve identification during neck dissection." Journal of Laryngology & Otology 119, no. 11 (November 2005): 906–8. http://dx.doi.org/10.1258/002221505774783511.
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Iatrogenic injury to the spinal accessory nerve (SAN) during neck dissection may result in significant and avoidable morbidity in the form of ’shoulder syndrome’. The authors describe a simple method, based on the anatomy of the sternocleidomastoid muscle (SCM), which allows consistent and rapid identification of the SAN in the upper neck during dissection, thereby facilitating its preservation.
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Laska, Tadeusz, and Kimberly Hannig. "Physical Therapy for Spinal Accessory Nerve Injury Complicated by Adhesive Capsulitis." Physical Therapy 81, no. 3 (March 1, 2001): 936–44. http://dx.doi.org/10.1093/ptj/81.3.936.
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Abstract Background and Purpose. The authors found no literature describing adhesive capsulitis as a consequence of spinal accessory nerve injury and no exercise program or protocol for patients with spinal accessory nerve injury. The purpose of this case report is to describe the management of a patient with adhesive capsulitis and spinal accessory nerve injury following a carotid endarterectomy. Case Description. The patient was a 67-year-old woman referred for physical therapy following manipulation of the left shoulder and a diagnosis of adhesive capsulitis by her orthopedist. Spinal accessory nerve injury was identified during the initial physical therapy examination, and a program of neuromuscular electrical stimulation was initiated. Outcomes. The patient had almost full restoration of the involved muscle function after 5 months of physical therapy. Discussion. This case report illustrates the importance of accurate diagnosis and suggests physical therapy intervention to manage adhesive capsulitis as a consequence of spinal accessory nerve injury.
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van Ouwerkerk, Willem J. R., Bernard M. J. Uitdehaag, Rob L. M. Strijers, Frans Nollet, Kurt Holl, Franz A. Fellner, and W. Peter Vandertop. "Accessory Nerve to Suprascapular Nerve Transfer to Restore Shoulder Exorotation in Otherwise Spontaneously Recovered Obstetric Brachial Plexus Lesions." Neurosurgery 59, no. 4 (October 1, 2006): 858–69. http://dx.doi.org/10.1227/01.neu.0000232988.46219.e4.
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Abstract OBJECTIVE: A systematic follow-up of infants with an obstetric brachial plexus lesion of C5 and C6 or the superior trunk showing satisfactory spontaneous recovery of shoulder and arm function except for voluntary shoulder exorotation, who underwent an accessory to suprascapular nerve transfer to improve active shoulder exorotation, to evaluate for functional recovery, and to understand why other superior trunk functions spontaneously recover in contrast with exorotation. METHODS: In 54 children, an accessory to suprascapular nerve transfer was performed as a separate procedure at a mean age of 21.7 months. Follow-up examinations were conducted before and at 4, 8, 12, 24, and 36 months after operation and included scoring of shoulder exorotation and abduction. Intraoperative reactivity of spinatus muscles and additional needle electromyographic responses were registered after electrostimulation of suprascapular nerves. Histological examination of suprascapular nerves was performed. Trophy of spinatus muscles was followed by magnetic resonance imaging scanning. The influence of perinatal variables and results of ancillary investigations on outcome were evaluated. RESULTS: Exorotation improved from 70 degrees to functional levels exceeding 0 degrees, except in two patients. Abduction improved in 27 patients, with results of 90 degrees or more in 49 patients. Electromyography at 4 months did not show signs of denervation in 39 out of 40 patients. Intraoperative electrostimulation of suprascapular nerves elicited spinatus muscle reaction in 44 out of 48 patients. Histology of suprascapular nerves was normal. Preoperative magnetic resonance imaging scans showed only minor wasting of spinatus muscles in contrast with major wasting after successful operations. CONCLUSION: An accessory to suprascapular nerve transfer is effective to restore active exorotation when performed as the primary or a separate secondary procedure in children older than 10 months of age. Contradictory spontaneous recovery of other superior trunk functions and integrity of suprascapular nerves, as well as absence of spinatus muscle wasting direct to central nervous changes are possible main causes for the lack of exorotation.
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Onitsuka, Tetsuro. "Spinal accessory nerve dysfunction and rehabilitation after neck dissections." JOURNAL OF JAPAN SOCIETY FOR HEAD AND NECK SURGERY 26, no. 3 (2017): 307–10. http://dx.doi.org/10.5106/jjshns.26.307.
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Polistena, Andrea, Monia Ranalli, Stefano Avenia, Roberta Lucchini, Alessandro Sanguinetti, Sergio Galasse, Fabio Rondelli, et al. "The Role of IONM in Reducing the Occurrence of Shoulder Syndrome Following Lateral Neck Dissection for Thyroid Cancer." Journal of Clinical Medicine 10, no. 18 (September 18, 2021): 4246. http://dx.doi.org/10.3390/jcm10184246.
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Lateral neck dissection (LND) leads to a significant morbidity involving accessory nerve injury. Modified radical neck dissection (MRND) aims at preservation of the accessory nerve, but patients often present with negative functional outcomes after surgery. The role of neuromonitoring (IONM) in the prevention of shoulder syndrome has not yet been defined in comparison to nerve visualization only. We retrospectively analyzed 56 thyroid cancer patients who underwent MRND over a period of six years (2015–2020) in a high-volume institution. Demographic variables, type of surgical procedure, removed lymph nodes and the metastatic node ratio, pathology, adoption of IONM and shoulder functional outcome were investigated. The mean number of lymph nodes removed was 15.61, with a metastatic node ratio of 0.2745. IONM was used in 41.07% of patients, with a prevalence of 68% in the period 2017–2020. IONM adoption showed an effect on post-operative shoulder function. There were no effects in 89.29% of cases, and temporary and permanent effects in 8.93% and 1.79%, respectively. Confidence intervals and two-sample tests for equality of proportions were used when applicable. Expertise in high-volume centres and IONM during MRND seem to be correlated with a reduced prevalence of accessory nerve lesions and limited functional impairments. These results need to be confirmed by larger prospective randomized controlled trials.
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Skurja, Michael, and John H. Monlux. "Case Studies: The Suprascapular Nerve and Shoulder Dysfunction." Journal of Orthopaedic & Sports Physical Therapy 6, no. 4 (February 1985): 254–58. http://dx.doi.org/10.2519/jospt.1985.6.4.254.
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Eisele, David W., Allen D. Hillel, Ronald E. Trachy, and J. W. Little. "Reinnervation of the Trapezius Muscle." Otolaryngology–Head and Neck Surgery 98, no. 1 (January 1988): 34–44. http://dx.doi.org/10.1177/019459988809800107.
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The eleventh cranial nerve shoulder syndrome, which results from denervation of the trapezius muscle, contributes significantly to the postoperative morbidity of radical neck dissections. Multiple techniques exist for the reinnervation of muscles that have injured motor nerves. Reinnervation of denervated trapezius muscles was examined in the New Zealand white rabbit by use of three techniques of reinnervation: (1) neuromuscular pedicle transfer of the accessory nerve from the trapezius muscle, (2) direct accessory nerve implantation, and (3) neuromuscular pedicle transfer of the accessory nerve from the sternocleidomastoid muscle. The reinnervated trapezius muscles were examined grossly by direct nerve stimulation, electrophysiologically by evoked electromyography, and histologically by enzymatic muscle staining and silver-reducing nerve staining. The gross, electrophysiologic, and histologic results confirmed successful reinnervation of the trapezius muscle within 6 weeks of operation. No significant difference was observed between the various techniques of reinnervation.
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Overland, J., J. C. Hodge, O. Breik, and S. Krishnan. "Surgical anatomy of the spinal accessory nerve: review of the literature and case report of a rare anatomical variant." Journal of Laryngology & Otology 130, no. 10 (June 8, 2016): 969–72. http://dx.doi.org/10.1017/s0022215116008148.
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AbstractObjective:To evaluate the prevalence of variations in the anatomical route of the spinal accessory nerve from the base of the skull to the point where it enters the trapezius muscle. A case report is used to demonstrate an example of a rare but clinically important anatomical variant of this nerve.Methods:An independent review of the literature using Medline, PubMed and Q Read databases was performed using combinations of terms including ‘spinal accessory nerve’, ‘anatomy’, ‘surgical anatomy’, ‘anatomical variant’, ‘cranial nerve XI’ and ‘shoulder syndrome’.Results:Our report demonstrates marked variation in spinal accessory nerve anatomy. At the point of crossing over the internal jugular vein, the spinal accessory nerve passes most commonly laterally (anterior) to the internal jugular vein. The reported incidence of this lateral relationship varies from 67 to 96 per cent. The nerve can also pierce the internal jugular vein, as demonstrated in our case study, with incidence ranging from 0.48 to 3.3 per cent.Conclusion:Anatomical variations of the spinal accessory nerve are not uncommon, and it is important for the surgeon to be aware of such variations when undertaking surgery in both the anterior and posterior triangles of the neck.
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van Wilgen, C. P., P. U. Dijkstra, B. F. A. M. van der Laan, J. T. Plukker, and J. L. N. Roodenburg. "Shoulder complaints after neck dissection; is the spinal accessory nerve involved?" British Journal of Oral and Maxillofacial Surgery 41, no. 1 (February 2003): 7–11. http://dx.doi.org/10.1016/s0266-4356(02)00288-7.
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Satbhai, N. G., K. Doi, Y. Hattori, and S. Sakamoto. "Contralateral lower trapezius transfer for restoration of shoulder external rotation in traumatic brachial plexus palsy: a preliminary report and literature review." Journal of Hand Surgery (European Volume) 39, no. 8 (November 8, 2013): 861–67. http://dx.doi.org/10.1177/1753193413512245.
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The importance of external rotation of the shoulder is well accepted. Patients with inadequate recovery of shoulder function after nerve transfers for a brachial plexus injury have difficulty in using their reconstructed limb. The options for secondary procedures to improve shoulder function are often limited, especially if the spinal accessory nerve has been used earlier for nerve transfer or as a donor nerve for a free functioning muscle transfer. We have used the contralateral lower trapezius transfer to the infraspinatus in three cases, to restore shoulder external rotation. All patients had significant improvement in shoulder external rotation (mean 97°; range 80°–110°) and improved disability of the arm, shoulder and hand scores. The rotation occurred mainly at the glenohumeral joint, and was independent of the donor side. All patients were greatly satisfied with the outcome. Contralateral lower trapezius transfer appears to help in overall improvement of shoulder function by stabilizing the scapula. The results have remained stable after mean follow-up of 58 months (range 12–86). No donor site deficit was seen in any patient.
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Huan, K. W. S. J., J. S. W. Tan, S. H. Tan, L. C. Teoh, and F. C. Yong. "Restoration of shoulder abduction in brachial plexus avulsion injuries with double neurotization from the spinal accessory nerve: a report of 13 cases." Journal of Hand Surgery (European Volume) 42, no. 7 (December 1, 2016): 700–705. http://dx.doi.org/10.1177/1753193416680725.
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In upper (C5-C7) and total (C5-T1) root avulsion brachial plexus injury, a method of double neurotization from a single donor spinal accessory nerve to two target nerves (suprascapular nerve and axillary nerve) may be done, leaving donor nerves available for reconstruction procedures to restore other aspects of upper limb function. A mean range of shoulder abduction of 91° (SD 25°) was achieved through this procedure in our study of 13 cases, of which seven cases were C5-C7 root avulsion and six cases were C5-T1 root avulsion brachial plexus injuries. Six of the former group and three of the latter group achieved >90° shoulder abduction. The technique of double neurotization from a single donor nerve provides favourable results in restoring shoulder abduction in avulsion brachial plexus injuries. Level of evidence: IV
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Foo, Eng Chuan, Ali Al-Samak, Khine Khine Lwin, Myat Thura, and Shwe Zin Tun. "193 Unusual presentation of hereditary neuropathy with liability to pressure palsies (HNPP)." Journal of Neurology, Neurosurgery & Psychiatry 93, no. 9 (August 12, 2022): e2.154. http://dx.doi.org/10.1136/jnnp-2022-abn2.237.
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IntroductionHNPP is an autosomal dominant disorder with estimated prevalence between 0.84- 16/100,000, commonly presenting as mononeuropathies involving pressure-prone areas. Presentation as both a brachial plexopathy and spinal accessory neuropathy is rare, and previously unreported.Case ReportA 30-year old female with no known medical co-morbidities presented with a 3-month history of right shoulder pain and weakness, and intermittent numbness of the elbow and hand. Examina- tion showed wasting of right trapezius and spinati muscles, shoulder droop, and weakness involving the right sternocleidomastoid, shoulder, and median and ulnar-supplied hand muscles. Nerve conduction studies and electromyography revealed axonal-loss pattern neuropathy of right suprascapular and spinal accessory nerves. Focal demyelination was seen in bilateral median and ulnar nerves across the wrists and elbows. Needle EMG showed denervation changes in right infraspinatus and trapezius muscles. Sub- sequent genetic testing of patient and her mother revealed deletion of chromosome 17p11.2 including PMP22. She improved clinically following a period of intensive physiotherapy.ConclusionHNPP typically affects pressure-prone sites such as the median, ulnar or peroneal nerves. Brachial plexopathy is uncommon, and involvement of spinal accessory nerve is very rare. Recognition of symptoms, with appropriate targeted electrodiagnostic and genetic investigations is important in achieving an accurate diagnosis and management.
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BALIARSING, A. S., K. DOI, and Y. HATTORI. "Bilateral Elbow Flexion Reconstruction with Functioning Free Muscle Transfer for Obstetric Brachial Plexus Palsy." Journal of Hand Surgery 27, no. 5 (October 2002): 484–86. http://dx.doi.org/10.1054/jhsb.2002.0777.
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A child suffered a bilateral obstetric brachial plexus palsy involving the C5 and C6 nerve roots. Abduction of the shoulder joints had recovered by 1 year, but elbow flexion did not recover on either side. Free gracilis muscle transfers were performed on both sides, at an interval of 6 months, to achieve elbow flexion. The spinal accessory nerve was used as the donor nerve.
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Seifman, Marc, and Scott Ferris. "Traumatic Suprascapular Nerve Injury at the Notch—A Reason for the Posterior Approach in Brachial Plexus Reconstruction." Journal of Reconstructive Microsurgery 33, no. 08 (June 21, 2017): 592–95. http://dx.doi.org/10.1055/s-0037-1603736.
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Background Optimal dynamic reconstruction of shoulder function requires a functional suprascapular nerve (SSN). Nerve transfer of the distal spinal accessory nerve (dSAN) to the SSN will in many cases restore very good supraspinatus and infraspinatus function. One potential cause of failure of this nerve transfer is an unrecognized more distal injury of the SSN. An anterior approach to this transfer does not allow for visualization of the nerve at the scapular notch which is a disadvantage when compared with a posterior approach to the SSN. Methods All patients of the senior author (S.F.) with traumatic brachial plexus injuries undergoing spinal accessory nerve to SSN transfer via the posterior approach were analyzed. Results Of the 58 patients, 11 (19.0%) demonstrated abnormal findings at the notch. In two of these 11 patients (18.2%), reconstruction was abandoned due to severe injury of the nerve. There was a higher rate of clavicular fractures in patients with SSN injuries at the notch, compared with no SSN injury at the notch (63.6 vs. 12.8%). Conclusion The dSAN to SSN transfer is a reliable reconstruction for restoration of shoulder external rotation and abduction. There is a high proportion of injuries to the nerve at the notch, which can be best appreciated from a posterior approach. The authors, therefore, advocate a posterior approach for this nerve transfer.
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Al-Qattan, M. M., and A. A. F. El-Sayed. "The Use of the Phrenic Nerve Communicating Branch to the Fifth Cervical Root for Nerve Transfer to the Suprascapular Nerve in Infants with Obstetric Brachial Plexus Palsy." BioMed Research International 2014 (2014): 1–4. http://dx.doi.org/10.1155/2014/153182.
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Traditionally, suprascapular nerve reconstruction in obstetric brachial plexus palsy is done using either the proximal C5 root stump or the spinal accessory nerve. This paper introduces another potential donor nerve for neurotizing the suprascapular nerve: the phrenic nerve communicating branch to the C5 root. The prevalence of this communicating branch ranges from 23% to 62% in various anatomical dissections. Over the last two decades, the phrenic communicating branch was used to reconstruct the suprascapular nerve in 15 infants. Another 15 infants in whom the accessory nerve was used to reconstruct the suprascapular nerve were selected to match the former 15 cases with regard to age at the time of surgery, type of palsy, and number of avulsed roots. The results showed that there is no significant difference between the two groups with regard to recovery of external rotation of the shoulder. It was concluded that the phrenic nerve communicating branch may be considered as another option to neurotize the suprascapular nerve.
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Bhandari, Prem. "Results of Distal Nerve Transfers in Restoration of Shoulder Function in C5 and C6 Root Avulsion Injury to the Brachial Plexus." Indian Journal of Neurotrauma 14, no. 01 (April 2017): 021–25. http://dx.doi.org/10.1055/s-0037-1604050.
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Background The lack of shoulder function following brachial plexus injury is a debilitating condition. Nerve root avulsion injury precludes a direct nerve repair. Under these circumstances, distal nerve transfer is a well-established technique in the restoration of shoulder abduction and external rotation. Methods Thirty patients with C5 and C6 root avulsion injury were treated with distal nerve transfers in the period between February 2009 and December 2012.The average denervation period was 5.6 months. Shoulder function was restored by posterior transfer of distal part of the spinal accessory nerve into the suprascapular nerve and transfer of the long head triceps branch of radial nerve to the anterior branch of axillary nerve. An additional nerve transfer was performed in four patients with winged scapula by transferring a part of thoracodorsal nerve into the long thoracic nerve. Results Twenty-seven patients recovered shoulder abduction; 18 scored M4 and 9 scored M3. Range of abduction averaged 118 degrees (range, 90–170 degrees). Nineteen patients restored external rotation with an average of 53 degrees (range: 30–70 degrees). Three patients failed to recover shoulder abduction though the joint regained stability. External rotation remained severely restricted in 11 patients. At final follow-up, winging of scapula improved in three of four patients following reinnervation of the serratus anterior muscle. Conclusion Nerve transfers, when performed close to the target muscles, restore good range and strength of shoulder abduction in most patients with C5 and C6 root avulsion injuries. However, return in external rotation is not as good as the recovery in abduction.